| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| ASSURANCE AGENCY LTD3 Filed as: EMPIRE HEALTH CHOICE ASSURANCE, INC | 3075 VANDERCAR WAY CINCINNATI, OH 45209 | ANTHEM BLUE CROSS BLUE SHIELD | $16K | — | $16K | 1.65% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| EMPIRE HEALTHCHOICE ASSURANCE, INC EIN 23-7391136 NONE | Non-monetary compensation; Recordkeeping and information management (computing, tabulating, data processing, etc.); Contract Administrator; Other commissions; Other services; Investment management fees paid directly by plan; Insurance agents and brokers; Claims processing; Insurance brokerage commissions and fees; Float revenue Service code 12 | — | $494K |
| LOCAL 21 ADMINISTRATIVE FUND NONE | Other fees; Direct payment from the plan Service code 50 | 1024 MCKINLEY STREET PEEKSKILL, NY 10566 | $324K |
| THE SEGAL COMPANY, INC. EIN 13-4835864 NONE | Insurance brokerage commissions and fees; Actuarial Service code 11 | — | $68K |
| BARNES, IACCARINO, VIRGINIA EIN 13-4212610 NONE | Legal; Direct payment from the plan Service code 29 | — | $28K |
| MSPC EIN 22-2951202 NONE | Direct payment from the plan; Accounting (including auditing) Service code 10 | — | $21K |
| DMI BOOKKEEPING & ACCOUNTING EIN 20-2400574 NONE | Accounting (including auditing); Direct payment from the plan Service code 10 | — | $11K |
| REYNOLDS CONSULTING SERVICES LLC EIN 11-2558102 NONE | Consulting (general); Investment management fees paid directly by plan Service code 16 | 410 JERICHO TURNPIKE JERICHO, NY 11753 | $8K |
Benefits declared on the Form 5500 main form (✓ = also has a Schedule A insurance contract; otherwise the benefit is funded out of plan assets or via a Schedule C TPA).
The plan reports several different headcounts depending on which form you read. Each one measures a different slice of the population.
| Active participants | 631 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 366 | Continuation coverage (COBRA, retiree health). |
| Total participants (= "Plan participants" tile) | 997 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Life insurance(2 contracts, 2 carriers) | COMPANION LIFE INSURANCE COMPANY | 1,058 | $368K |
| Stop-loss / reinsurancereinsurance | ANTHEM BLUE CROSS BLUE SHIELD | 719 | $464K |
| Other | MUTUAL OF OMAHA INSURANCE COMPANY | 658 | $3K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 1,058 | — |
Why the numbers differ. Form 5500 line 6 counts employees + retirees + beneficiaries; no dependents. Schedule A persons-covered counts everyone enrolled, including spouses and children, so it usually exceeds line 6 by 30-60% on a working-age workforce. The medical row is normally the broadest single line because it has the highest take-up; dental/vision/life often dip below it. Stop-loss / reinsurance contracts sometimes report the carrier's full underwriting pool rather than this filer's headcount; the row is shown for transparency but shouldn't be read as "people in this plan."
Broker comp is under 1% of premium on a >$1M plan. Plan may be flying solo or paying a flat fee — consultant sales target.